Results of the Chronic Heart Failure Intervention to Improve MEdication Adherence study: A randomized intervention in high-risk patients.

BACKGROUND: Poor adherence to evidence-based medications in heart failure (HF) is a major cause of avoidable hospitalizations, disability, and death. To test the feasibility of improving medication adherence, we performed a randomized proof-of-concept study of a self-management intervention in high-risk patients with HF. METHODS: Patients with HF who screened positively for poor adherence (<6 Morisky Medication Adherence Scale 8-item) were randomized to either the intervention or attention control group. In the intervention group (n = 44), a nurse conducted self-management training before discharge that focused on identification of medication goals, facilitation of medication-symptom associations, and use of a symptom response plan. The attention control group (n = 42) received usual care; both groups received follow-up calls at 1 week. However, the content of follow-up calls for the attention control group was unrelated to HF medications or symptoms. General linear mixed models were used to evaluate the magnitude of change in adherence and symptom-related events at 3-, 6-, and 12-month follow-up clinic visits. Efficacy was measured as improved medication adherence using nurse-assessed pill counts at each time point. RESULTS: Pooled over all time points, patients in the intervention group were more likely to be adherent to medications compared with patients in the attention control group (odds ratio 3.92, t = 3.51, P = .0007). CONCLUSIONS: A nurse-delivered, self-care intervention improved medication adherence in patients with advanced HF. Further work is needed to examine whether this intervention can be sustained to improve clinical outcomes.

Evaluation of neonatal peripherally inserted central catheter tip movement in a consistent upper extremity position.

OBJECTIVE: To compare the effect of standardized upper extremity position versus varied upper extremity positions on neonatal peripherally inserted central catheter (PICC) tip placement and movement. Secondary outcomes assessed were compliance with education, implementation, and complication rates. STUDY DESIGN: Tip movement was analyzed between 136 post-PICC insertion x-ray pairs from 72 infants in the 6 months before and after standardization of upper extremity position. Tip movement was regressed over days between x-ray pairs, respiratory support, absolute weight change, and insertion vein. RESULTS: There was no difference in PICC tip movement among varied analysis pairs or when standard position pairs were compared with pairs that were in a same nonstandard position. Days between x-rays, respiratory support, absolute weight change, and insertion vein did not predict tip movement. Attendance at education sessions was 100%. Compliance with the new standard was 73%. Complication rates were not significantly different. CONCLUSION: Standardization of upper extremity position during neonatal PICC confirmation x-rays did not alter PICC tip movement.

The promise of the state space approach to time series analysis for nursing research.

BACKGROUND: Nursing research, particularly related to physiological development, often depends on the collection of time series data. The state space approach to time series analysis has great potential to answer exploratory questions relevant to physiological development but has not been used extensively in nursing. OBJECTIVES: The aim of the study was to introduce the state space approach to time series analysis and demonstrate potential applicability to neonatal monitoring and physiology. METHODS: We present a set of univariate state space models; each one describing a process that generates a variable of interest over time. Each model is presented algebraically and a realization of the process is presented graphically from simulated data. This is followed by a discussion of how the model has been or may be used in two nursing projects on neonatal physiological development. RESULTS: The defining feature of the state space approach is the decomposition of the series into components that are functions of time; specifically, slowly varying level, faster varying periodic, and irregular components. State space models potentially simulate developmental processes where a phenomenon emerges and disappears before stabilizing, where the periodic component may become more regular with time, or where the developmental trajectory of a phenomenon is irregular. DISCUSSION: The ultimate contribution of this approach to nursing science will require close collaboration and cross-disciplinary education between nurses and statisticians.

The effects of environmental noise and infant position on cerebral oxygenation.

PURPOSE: To assess how different infant positions and peak sound levels affected cerebral oxygen saturation over time. SUBJECTS: Twenty-four premature infants who were born less than 32 weeks' gestational age without congenital cardiac, neurologic, and gastrointestinal anomalies. DESIGN: Repeated-measures design with the first observation between 2 and 48 hours of life; once again between 49 and 96 hours of life; on day of life 7; and every 7 days thereafter until discharge home, transfer to another hospital, or 40 weeks postmenstrual age, whichever came first. METHODS: Continuous sound levels (decibels) were obtained and 2 infant positions were performed while measuring cerebral oxygen saturation during 40-minute observation periods. MAIN OUTCOME MEASURES: Effect of peak sound and differences in infant position on cerebral oxygen saturation. RESULTS: Peak sound levels 5 dB above the average ambient sound level did not significantly change cerebral oxygen saturation values. Differences in cerebral oxygenation were significantly less when infants were changed from a supine, head midline position to a right lateral, 15° head elevation compared with a left lateral, 0° elevation position. CONCLUSIONS: Aspects of the current neonatal intensive care unit environment do not appear to affect cerebral oxygen saturation.

Affecting perceptions of harm and addiction among college waterpipe tobacco smokers.

INTRODUCTION: The spread of waterpipe tobacco use among youth may be due in part to perceptions that waterpipe tobacco use is safer than other tobacco products, such as cigarettes. In two pilot studies, we sought to modify college waterpipe smokers' perceived risks and worry about waterpipe tobacco smoking. METHODS: We conducted two web-based studies that varied whether college waterpipe users received information on (a) spread of and use of flavored tobacco in waterpipe and (b) harms of waterpipe smoking. Study 1 (N = 91) tested the "incremental" effects on perceptions of risk and worry of adding information about harms of waterpipe smoking to information on the spread of waterpipe and use of flavorings in the tobacco. Study 2 (N = 112) tested the effects on perceptions of risk and worry of reviewing information about harms of waterpipe smoking compared to a no information control group. In Study 1 only, we assessed as part of a 6-month follow-up (n = 70) the percentage of participants who reported no longer using waterpipe. RESULTS: Pooling data from both studies, participants who received information about the harms of waterpipe smoking reported greater perceived risk and worry about harm and addiction and expressed a stronger desire to quit. In Study 1, 62% of participants in the experimental group versus 33% in the control group reported having stopped waterpipe use. CONCLUSIONS: These are the first studies to show that perceptions of addiction and harm from waterpipe use can be modified using minimally intensive interventions; such interventions show promise at decreasing waterpipe use.

Advances in mediation analysis can facilitate nursing research.

BACKGROUND: Two recent advances in the statistical methods for testing hypotheses about mediation effects are important for nursing science. First, bootstrap sampling distributions provide more accurate tests of hypotheses about mediated effects. Second, methods for testing statistical hypotheses about subgroup differences in mediation models (moderated mediation) are now well developed. OBJECTIVE: The aims of this study were to demonstrate the use and relatively simple computation of bootstrap sampling distributions in tests of mediation effects and to demonstrate a recently refined method for testing hypotheses about moderated mediation. METHOD: Using hypothetical data, a step-by-step demonstration was provided of the construction of a bootstrap sampling distribution for a correlation coefficient. Then, tests of mediation and moderated mediation were demonstrated using data from a clinical trial of an intervention for caregivers of patients with Parkinson's disease or Alzheimer's disease. In a model hypothesizing that mutuality between caregiver and care recipient mediates the effect of objective on subjective levels of caregiver burden, the bootstrap sampling distribution was calculated of the mediation effect and, from that, two types of 95% confidence intervals for it. Then the hypothesis was tested that the mediating effect of mutuality was stronger for caregivers of patients with Parkinson's disease than for caregivers of patients with Alzheimer's disease. CONCLUSIONS: Statistical hypothesis testing should never dictate all conclusions. However, the statistical advances in mediation analysis described here will facilitate nursing research as both nurse scientists and methodologists understand their assumptions and logic.

Impact of health portal enrollment with email reminders on adherence to clinic appointments: a pilot study.

BACKGROUND: Internet portal technologies that provide access to portions of electronic health records have the potential to revolutionize patients' involvement in their care. However, relatively few descriptions of the demographic characteristics of portal enrollees or of the effects of portal technology on quality outcomes exist. This study examined data from patients who attended one of seven Duke Medicine clinics and who were offered the option of enrolling in and using the Duke Medicine HealthView portal (HVP). The HVP allows patients to manage details of their appointment scheduling and provides automated email appointment reminders in addition to the telephone and mail reminders that all patients receive. OBJECTIVE: Our objective was to test whether portal enrollment with an email reminder functionality is significantly related to decreases in rates of appointment "no-shows," which are known to impair clinic operational efficiency. METHODS: Appointment activity during a 1-year period was examined for all patients attending one of seven Duke Medicine clinics. Patients were categorized as portal enrollees or as nonusers either by their status at time of appointment or at the end of the 1-year period. Demographic characteristics and no-show rates among these groups were compared. A binomial logistic regression model was constructed to measure the adjusted impact of HVP enrollment on no-show rates, given confounding factors. To demonstrate the effect of HVP use over time, monthly no-show rates were calculated for patient appointment keeping and contrasted between preportal and postportal deployment periods. RESULTS: Across seven clinics, 58,942 patients, 15.7% (9239/58,942) of whom were portal enrollees, scheduled 198,199 appointments with an overall no-show rate of 9.9% (19,668/198,199). We found that HVP enrollees were significantly more likely to be female, white, and privately insured compared with nonusers. Bivariate no-show rate differences between portal enrollment groups varied widely according to patient- and appointment-level attributes. Large reductions in no-show rates were seen among historically disadvantaged groups: Medicaid holders (OR = 2.04 for nonuser/enrollee, 5.6% difference, P < .001), uninsured patients (OR = 2.60, 12.8% difference, P < .001), and black patients (OR = 2.13, 8.0% difference, P < .001). After fitting a binomial logistic regression model for the outcome of appointment arrival, the adjusted odds of arrival increased 39.0% for portal enrollees relative to nonusers (OR = 1.39, 95% CI 1.22 - 1.57, P < .001). Analysis of monthly no-show rates over 2 years demonstrated that patients who registered for portal access and received three reminders of upcoming appointments (email, phone, and mail) had a 2.0% no-show rate reduction (P < .001), whereas patients who did not enroll and only received traditional phone and mail reminders saw no such reduction (P < .09). CONCLUSIONS: Monthly no-show rates across all seven Duke Medicine clinics were significantly reduced among patients who registered for portal use, suggesting that in combination with an email reminder feature, this technology may have an important and beneficial effect on clinic operations.

Potential Pitfalls in Collecting and Analyzing Longitudinal Data from Chronically Ill Populations.

Research on the prevention and management of chronic illnesses involves understanding changes in complex and interrelated aspects of each individual. To capture these changes or to control for them, nursing and health research needs to be longitudinal. However, there are a number of potential pitfalls in analyzing longitudinal data from a chronically ill population. This paper will examine four major pitfalls: selection of time points, measurement, choosing appropriate statistical procedures, and missing values. Although the frequency of data collection is often driven primarily by practical concerns, it will affect the results. In addition, outcome measures may capture different constructs at different points in times. Traditional analysis techniques often have assumptions about data characteristics that are violated in clinical populations. Missing values are common in research with chronically ill individuals because of problems of subject retention and because individuals have frequent medical complications. Solutions to these pitfalls are also discussed.

Patterns of psychological distress in mothers of preterm infants.

Mothers of preterm infants experience significant psychological distress, with elevated levels of inter-correlated depressive, stress, anxiety and post-traumatic stress symptoms. In a sample of racially and ethnically diverse mothers of preterm infants, we identified differing patterns of psychological distress during infant hospitalization and examined the effect of these psychological distress patterns on longitudinal trajectories of each psychological distress measure and on maternal perceptions of the child over the first year of the infant's life. Mothers of preterm infants (N=232) completed five questionnaires assessing depressive symptoms, anxiety, post-traumatic stress symptoms, stress due to infant appearance, and stress due to parental role alteration during enrollment during the neonatal hospitalization, discharge, and at 2, 6, and 12 months of age adjusted for prematurity. Latent class analysis on the enrollment psychological distress variables allowed us to identify five sub-groups of mothers exhibiting similar patterns of psychological distress, differing primarily in degree and type: low distress, moderate distress, high NICU-related distress, high depressive and anxiety symptoms, and extreme distress. These classes continued to show different longitudinal trajectories for the psychological distress measures through 12 months corrected age. Mothers in the extreme distress class and, to a lesser degree, mothers in the high depressive and anxiety symptom class remained at risk of significant psychological distress one year after discharge and had less positive perceptions of their child (greater worry and higher perceptions of child vulnerability). In conclusion, distinctive sub-groups of mothers during hospitalization had different patterns of psychological distress throughout the 12-month period and may require different interventions in the NICU.

Relationships among factual and perceived knowledge of harms of waterpipe tobacco, perceived risk, and desire to quit among college users.

Waterpipe tobacco smoking is increasing in the United States among college students. Through a web-based survey, we explored associations among factual and perceived knowledge, perceived risks and worry about harm and addiction, and desire to quit among 316 college waterpipe tobacco smoking users. Overall, factual knowledge of the harm of waterpipe tobacco smoking was poor, factual and perceived knowledge was weakly correlated, both forms of knowledge were related inconsistently to perceived risks and worry, and neither form of knowledge was associated with the desire to quit. Findings provide preliminary insights as to why knowledge gaps may not predict cessation among waterpipe users.

Maternally administered interventions for preterm infants in the NICU: effects on maternal psychological distress and mother-infant relationship.

Although studies have examined the effects of interventions focused on preterm infants, few studies have examined the effects on maternal distress (anxiety, depressive symptoms, post-traumatic stress symptoms, parenting stress) or parenting. This study examined the effects of the auditory-tactile-visual-vestibular (ATVV) intervention and kangaroo care (KC) on maternal distress and the mother-infant relationship compared to an attention control group. 240 mothers from four hospitals were randomly assigned to the three groups. Maternal characteristics in the three groups were similar: 64.1% of ATVV mothers, 64.2% of KC mothers, and 76.5% of control mothers were African American; maternal age averaged 26.3 years for ATVV mothers, 28.1 for KC mothers, and 26.6 for control mothers; and years of education averaged 13.6 for ATVV and KC mothers, and 13.1 for control mothers. Mothers only differed on parity: 68.4% of ATVV and 54.7% of KC mothers were first-time mothers as compared to 43.6% of control mothers. Their infants had a similar mean gestational ages (27.0 weeks for ATVV, 27.2 for KC, and 27.4 for control) and mean birthweights (993 g for ATVV, 1022 for KC, and 1023 for control). Mothers completed questionnaires during hospitalization, and at 2, 6 and 12 months corrected age on demographic characteristics, depressive symptoms, state anxiety, post-traumatic stress symptoms, parenting stress, worry about child health, and child vulnerability (only at 12 months). At 2 and 6 months, 45-min videotapes of mother-infant interactions were made, and the HOME Inventory was scored. Behaviors coded from the videotapes and a HOME subscale were combined into five interactive dimensions: maternal positive involvement and developmental stimulation and child social behaviors, developmental maturity, and irritability. Intervention effects were examined using general linear mixed models controlling for parity and recruitment site. The groups did not differ on any maternal distress variable. Kangaroo care mothers showed a more rapid decline in worry than the other mothers. The only interactive dimensions that differed between the groups were child social behaviors and developmental maturity, which were both higher for kangaroo care infants. Change over time in several individual infant behaviors was affected by the interventions. When mothers reported on the interventions they performed, regardless of group assignment, massage (any form including ATVV) was associated with a more rapid decline in depressive symptoms and higher HOME scores. Performing either intervention was associated with lower parenting stress. These findings suggest that as short-term interventions, KC and ATVV have important effects on mothers and their preterm infants, especially in the first half of the first year.

Feasibility and preliminary effects of a virtual environment for adults with type 2 diabetes: pilot study.

BACKGROUND: Innovative interventions that empower patients in diabetes self-management (DSM) are needed to provide accessible, sustainable, cost-effective patient education and support that surpass current noninteractive interventions. Skills acquired in digital virtual environments (VEs) affect behaviors in the physical world. Some VEs are programmed as real-time three-dimensional representations of various settings via the Internet. For this research, a theoretically grounded VE that facilitates DSM was developed and pilot tested. It offered weekly synchronous DSM education classes, group meetings, and social networking in a community in which participants practiced real world skills such as grocery shopping, exercising, and dining out, allowing for interactive knowledge application. The VE was available 24/7 on the Internet, minimizing access barriers. OBJECTIVE: The objective of this study was to evaluate the feasibility and efficacy of participation in a VE for DSM education and support. METHODS: This study utilized a single group, pre-mid-post measure design. At 0, 3, and 6 months, we assessed participants' perceived VE usability and usefulness, self-efficacy, diabetes self-management behaviors, perceived social support, and diabetes knowledge using validated survey measures; and we recorded metabolic indicators (HbA1c, BP, BMI). Process data were continuously collected in the VE (log-ins, voice recordings, locations visited, objects interacted with, and movement). Data analysis included descriptive statistics, t tests to evaluate changes in mediators and outcomes over time, and depiction of utilization and movement data. RESULTS: We enrolled 20 participants (13/20, 65% white, 7/20, 35% black), with an age range of 39-72 years (mean age, 54 years) and diabetes duration from 3 months to 25 years. At baseline, 95% (18/19) and 79% (15/19) of participants rated usefulness and ease of use as high on validated surveys with no significant changes at 3 or 6 months. Participants logged into the site a mean of 2.5 hours/week over the course of 6 months. High DSM class attendance was reflected by the largest percentage of time spent in the classroom (48.6%). Self-efficacy, social support, and foot care showed significant improvement (P<.05). There were improvement trends in clinical outcomes that were clinically meaningful but did not reach statistical significance given the small sample size. CONCLUSIONS: Because relatively little is known about usability, acceptability, and efficacy of health interventions in VEs, this study constitutes an important, innovative first step in exploring the potential of VEs for facilitating DSM. The preliminary data suggest that VEs provide a feasible and useful platform for patients and educators that affects self-management and related mediators. Flexible access to both synchronous and asynchronous diabetes education, skill building activities, and support from a home computer remove barriers to attending clinic-based meetings. This program has potential for improving DSM in an easily disseminated alternative model.

A pilot study to examine maturation of body temperature control in preterm infants.

OBJECTIVE: To test instrumentation and develop analytic models to use in a larger study to examine developmental trajectories of body temperature and peripheral perfusion from birth in extremely low-birth-weight (EBLW) infants. DESIGN: A case study design. SETTING: The study took place in a Level 4 neonatal intensive care unit (NICU) in North Carolina. PARTICIPANTS: Four ELBW infants, fewer than 29 weeks gestational age at birth. METHODS: Physiologic data were measured every minute for the first 5 days of life: peripheral perfusion using perfusion index by Masimo and body temperature using thermistors. Body temperature was also measured using infrared thermal imaging. Stimulation and care events were recorded over the first 5 days using video which was coded with Noldus Observer software. Novel analytical models using the state space approach to time-series analysis were developed to explore maturation of neural control over central and peripheral body temperature. RESULTS/CONCLUSION: Results from this pilot study confirmed the feasibility of using multiple instruments to measure temperature and perfusion in ELBW infants. This approach added rich data to our case study design and set a clinical context with which to interpret longitudinal physiological data.

Maternal satisfaction with administering infant interventions in the neonatal intensive care unit.

OBJECTIVE: To examine mothers' satisfaction with administering interventions for their preterm infants and with the helpfulness of the study nurse by comparing massage with auditory, tactile, visual, and vestibular stimulation (ATVV intervention), kangaroo care, and education about equipment needed at home and to explore whether mother and infant characteristics affected maternal satisfaction ratings. DESIGN: Three-group experimental design. SETTING: Four neonatal intensive care units (NICUs) (two in North Carolina, two in Illinois). PARTICIPANTS: Two hundred and eight (208) preterm infants and their mothers. METHODS: When the infant was no longer critically ill, mother/infant dyads were randomly assigned to ATVV, kangaroo care, or the education group all taught by study nurses. At discharge and 2 months corrected age, mothers completed questionnaires. RESULTS: All groups were satisfied with the intervention and with nurse helpfulness, and the degree of satisfaction did not differ among them. Intervention satisfaction, but not nurse helpfulness, was related to recruitment site. Older, married, and minority mothers were less satisfied with the intervention but only at 2 months. Higher anxiety was related to lower intervention satisfaction at discharge and lower ratings of nurse helpfulness at discharge and 2 months. More depressive symptoms were related to lower nurse helpfulness ratings at 2 months. CONCLUSIONS: Mothers were satisfied with interventions for their infants regardless of the intervention performed. Maternal satisfaction with the intervention was related to recruitment site, maternal demographic characteristics, and maternal psychological distress, especially at 2 months. Thus, nursing interventions that provide mothers with a role to play in the infant's care during hospitalization are particularly likely to be appreciated by mothers.

Measuring addiction propensity and severity: the need for a new instrument.

Drug addiction research requires but lacks a valid and reliable way to measure both the risk (propensity) to develop addiction and the severity of manifest addiction. This paper argues for a new measurement approach and instrument to quantify propensity to and severity of addiction, based on the testable assumption that these constructs can be mapped onto the same dimension of liability to addiction. The case for this new direction becomes clear from a critical review of empirical data and the current instrumentation. The many assessment instruments in use today have proven utility, reliability, and validity, but they are of limited use for evaluating individual differences in propensity and severity. The conceptual and methodological shortcomings of instruments currently used in research and clinical practice can be overcome through the use of new technologies to develop a reliable, valid, and standardized assessment instrument(s) to measure and distinguish individual variations in expression of the underlying latent trait(s) that comprises propensity to and severity of drug addiction. Such instrumentation would enhance our capacity for drug addiction research on linkages and interactions among familial, genetic, psychosocial, and neurobiological factors associated with variations in propensity and severity. It would lead to new opportunities in substance abuse prevention, treatment, and services research, as well as in interventions and implementation science for drug addiction.